Burnout

Depression and Burnout

The two conditions are non-identical twins.

Posted Nov 07, 2019

Understanding psychologically impairing conditions is vital. Depression and burnout are similar but distinct entities.

The field of psychiatry has recognized depression as “major clinical depression”—a psychiatric disorder with signs, symptoms, and effective treatments. The phenomenon of “burnout” has emerged over the last decades. Its impact on how medical doctors experience occupational distress can compromise patient safety. This chronic stress increases doctors leaving medicine. Attention to burnout prevention is a primary intervention.

The term “burnout” originated in the 1940s to describe the point a jet or rocket engine stops operating. In the 1970s, the psychiatrist Herbert Freudenberger used burnout to describe overworked volunteers in mental health clinics. In the early 1980s, social psychologist Christina Maslach used “burnout” to describe clinicians who lost concern and positive feelings for clients. Maslach’s work expanded to delineate the syndrome in an overstressed work environment.

Statistics (Kane, 2019) show that in 15,000 physicians, 39% of psychiatrists and 50% of MDs from other subspecialties self-identify as “burned-out.”  About 39% of non-physicians report dissatisfaction with work-life balance.

from author, Frank John Ninivaggi MD
Depression or Burnout?
Source: from author, Frank John Ninivaggi MD

Depression versus Burnout 

While depression and burnout overlap, they differ—each with characteristic causes and treatments. Burnout being newer will be discussed first.

Burnout

Burnout is not a medical disorder; it is an occupational condition. The International Classification of Diseases (ICD-11) adopted in 2019 and effective in 2022 assigns “job burnout” with the condition code QD85.

The prestigious Mayo Clinic shows satisfaction with these work-life balance statistics: 

  • about 66% of the general population are satisfied
  • about 33% of physicians feel satisfied

An updated study by Shanafelt et al., 2019 showed burnout and satisfaction with work-life integration among US physicians improved by about 1.6% between 2014 and 2017. Physicians in hospitals and corporations are more dissatisfied than independent doctors. About 69% of corporate and hospital-based physicians report burnout compared with 51% of those not working in institutions. All groups report lowered empathy parallel to feelings of burnout.

Three clusters define the burnout syndrome:

1. Emotional and physical exhaustion

2. Depersonalization and cynicism

3. A diminished sense of personal effectiveness

Exhaustion comprises physical fatigue and emotional depletion with slow recuperation and unresolved emotional dissonance. Appetite and sleep undergo a roller-coaster pattern. The sufferer is unhappy but not usually depressed.

Depersonalization is the sensation of unreality about oneself or the environment. It occurs under extreme stress or fatigue. Such tension is dissident and potentially trauma-inducing. Cynicism about the sincerity of others and one’s competence organize into numbing attitudes, judgments, and demoralizing criticisms. Overwhelming stress leads to ongoing physical and emotional withdrawal. For example, frequent absenteeism may show the distancing of burnout.

A diminished sense of personal effectiveness accompanies feeling a loss of control in one’s job. With this, those self-identified as burned out feel increasingly incapable of thinking clearly, problem-solving, and taking action.

While burnout may occur in any job context, it is most notable in medicine—the overall rate is about 54 % of all physicians. The specific cause is job-related—“administrative burden” and no control over the workload, i.e., prolonged stress. Since burnout affects one’s occupational status globally, no standardized treatments exist. “Work-life imbalance” is a phrase almost synonymous with the burnout syndrome.

Individual stress reduction, mindfulness approaches, improved lifestyle routines, and reducing job-related stressors are recognized interventions. Feeling powerless is present; meaningful rewards and a supportive environment are not available. Typically, depression is not invariably part of burnout but may occur in 30 to 50%. The burned-out sufferer does not feel inappropriate guilt nor contemplate self-harm.

Depression

Depression is termed “major depressive disorder” in the diagnostic and statistical manual of mental disorders, DSM-5, with an average lifetime prevalence of about 12%. The mean age of onset is about 40 years. Causes are combinations of genetic, familial, and environmental triggers, not just the stress key to burnout. Clinical depression is pervasive in all areas of one’s life, not just the workplace. Treatments involve psychotropic medications and psychosocial and behavioral therapies. Specific signs and symptoms include 

  • Depressed mood
  • Diminished interest or pleasure in life’s activities—“anhedonia”
  • Weight loss (over 5% of typical weight in one month) or increase or decrease in appetite
  • Too little or too much sleep
  • Agitation or excessive slowness
  • Fatigue or shallow energy level
  • Feelings of worthlessness or inappropriate guilt with chronic self-criticism and loathing
  • Diminished concentration
  • Recurrent thoughts of death

Impairment extends to social, occupational, and everyday functioning, not just one’s job.

No symptom is exclusive to a medical condition, medication, or illicit drug use.

No medical tests or biomarkers have been routinely identified. Two-thirds of all depressed patients have suicidal ideation, and 10 to 15% commit suicide.

Grief is not depression. Grief is characterized by feeling empty and memories of the lost person. Anhedonia, self-harm, and suicidal ideation are not part of the grief reaction and mourning. Self-esteem is preserved. Grief requires no medical treatment and resolves in about one year.

Depression is pervasive, not just occupational. A major depressive episode includes hopelessness, suicidality, and delusional thoughts—all absent in both grief and burnout. Strong evidence shows that psychopharmacological interventions and psychotherapies are effective in treating clinical depression.

Using Burnout Awareness to Prevent the Syndrome

Depression and occupational burnout are impairing conditions. Depression is a psychiatric diagnosis. Job burnout, not a diagnosis, is a workplace phenomenon. Depressive disorders are well-studied, and treatments abound. Once believed only to be a healthcare provider condition, burnout can affect everyone in the workforce. Personal, social, and economic repercussions follow. Interventions for burnout are still evolving.

Burnout prevention recognizes its development. The burnout mismatch between the individual and the job is outstanding. For doctors, “physician engagement” with “administrative alignment” of mutual values is crucial. The primary goal of burnout prevention is stopping the burnout cycle (Ninivaggi, 2019). 

At first, enthusiasm is present. Prolonged work-related stress, not isolated and short-term, bring job dissatisfaction. Disappointment and fatigue set in; workers distance themselves and disconnect. Frustration leads to cynicism and indifference. Powerlessness to change the situation accompanies professional alienation. Burnout then emerges as exhaustion, depersonalization, and a sense of failure—all leading to contemplating or leaving one’s job. 

Individual strategies promote life-work integration upgraded with mindfulness, stress reduction, diet, exercise, and time management. Coaching and mentoring show how well the process is going. This feedback refines improvement plans. Learning compassion for self and others builds resilience. This minimizes the adverse effects of stress, the core of emerging burnout.

Sustainability ensures work-life integration—enhanced well-being, self-care, and striving to encourage organizational change and its stressors. 

References

Kane, L. (2019). "Medscape national physician burnout & depression report 2019." https://www.medscape.comslideshow/2019-lifestyle-burnout-depression-6011056#1. Published on January 16, 2019. Accessed October 15, 2019.

Ninivaggi, F.J. (2019) Learned Mindfulness: Physician Engagement and MD Wellness. Cambridge: MA. Elsevier/Academic Press.

Shanafelt, T. D., West, C. P., Sinsky, C., Trockel, M., Tutty, M., Satele, D. V., et al. (2019). "Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017." Mayo Clinic Proceedings. PII: S0025-6196(18)30938-8. https://doi.org/10.1016/j.mayocp.2018.10.023. [Epub ahead of print].